Provider Demographics
NPI:1255869137
Name:JORDAN, KIMBERLY A (OTR/L)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:JORDAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 WELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7618
Practice Address - Country:US
Practice Address - Phone:910-632-2421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-23
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2357225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist